Fig. 2.1
The Veress needle is 14-gauge and 12–15 cm in length
It has an outer beveled tip that cuts through the tissue. The blunt tip stylet of the inner cannula is retractable and serves as a safety mechanism. In Fig. 2.2, the mechanism of entry of the Veress needle is demonstrated. As the needle traverses the fascia and enters the peritoneum, the blunt tip springs forward upon entering an open space. This blunt stylet protects the abdominal contents from the sharp outer cannula. Before the introduction of the Veress needle into the abdomen, it can be confirmed that the mechanism is intact as shown in Fig. 2.3.
Fig. 2.2
The mechanism of a Veress needle entry is demonstrated in this illustration. As the needle is introduced to the abdominal cavity, the blunt stylet protects the abdominal contents from the sharp outer cannula
Fig. 2.3
(a) The length of the Veress needle may vary between 12–15 cm. (b) The Veress needle is shown with the obturator extended
The most favored site for introduction of the Veress needle is at the level of the umbilicus. It is at this level that the fascia layers are most tethered, making penetration into the abdomen easier. However, if this site is not available because of a previous scar or hernia, other sites may be used. To introduce the Veress needle into the abdomen, a periumbilical, vertical incision is made. The incision is lengthened to ensure that it can accommodate the outer diameter of the trocar; this helps to prevent excess force being placed on the trocar during insertion.
Problem: A too large or too small skin incision.
Solution: To ensure that the incision is the correct length, take the outer cannula of the trocar and make an impression on the skin. This serves as a guide for the length of the incision.
The Veress needle is then advanced at a right angle to the fascia, simultaneously lifting the abdominal wall away from the underlying viscera by using towel clips as shown in Figs. 2.4 and 2.5.
Fig. 2.4
Using towel clips, the Veress needle was introduced into the abdominal cavity
Fig. 2.5
By lifting the abdominal cavity away from the underlying viscera, the abdominal contents are protected
As the needle advances through the fascia and the peritoneum, two distinct pops may be felt. The first pop occurs when the abdominal wall fascia is traversed and a second pop is associated with an audible click as the inner cannula springs forward upon entering the peritoneum.
Problem: Insufflation within omentum giving a bubbly appearance as shown in Fig. 2.6.
Fig. 2.6
Insufflation within the omentum gives a bubbly appearance as shown in this illustration
Solution: After inserting the secondary trocar, a nick can be made to deflate the bubbly appearing omentum.
Problem: Injury to deep structures including great vessels.
Solution: Deep penetration of the Veress needle into the abdominal cavity should be avoided to minimize the risk of great vessel injury.
To check for correct placement of the needle, a 10 cc syringe with saline is attached to the Veress needle. Initially, it is aspirated to look for blood, enteric contents, or air. After this, saline is irrigated to see if free flow into the abdomen is possible. The syringe barrel is then removed and the saline in the Veress needle should flow freely into the abdomen because of negative pressure as shown in Fig. 2.7.
Fig. 2.7
After the abdominal cavity has been entered with the Veress needle, a syringe with fluid is used to perform the drop test
If this does not occur, the needle is in the wrong position and should be removed.
Problem: Blood is present in the aspirate – if blood is aspirated from the Veress needle, a vascular injury is suspected.
Solution: The needle should be removed and replaced. Once access is obtained, the puncture site as well as the retroperitoneum should be inspected for evidence of vascular injury or expanding hematoma. During this time, if the patient becomes hemodynamically unstable and vascular control is not feasible laparoscopically, emergency laparotomy should be performed.
Problem: Excessive air or enteric contents are present in the aspirate. In this situation, an enteric injury is suspected.
Solution: The needle is left in place, as it might be difficult to isolate the site of injury if the needle is removed and also result in further spillage of enteric contents. A new access site should be chosen for laparoscopic access and the initial needle placement can be confirmed and any perforation repaired. The decision to repair the injury laparoscopically or via an open approach is based on the experience of the surgeon and the extent of the injury. In most cases, the Veress needle is a forgiving instrument and does not require repair. Patients should be given antibiotics for a few days.
Although these complications are rare (occurring in 0.05–0.2 % of cases), they do require vigilance (1).
2.4.3 Open Technique
In an attempt to increase the safety for insertion of the initial trocar, Hasson introduced a method to obtain laparoscopic access through an open technique. This technique is especially useful when a patient has undergone previous abdominal surgeries.
A semicircular incision is created around the umbilicus. An alternate position may be chosen in certain situations, usually lateral to rectus muscle, and in a way to avoid major vascular structures of the abdominal wall as shown in Fig. 2.8.
Fig. 2.8
The abdominal wall structures are noted in this illustration. Note where the inferior and superior epigastric artery is in relation to the rectus abdominis muscle
Using a combination of two army-navy retractors, the subcutaneous fat is cleared from the fascia. A small 1–2 cm incision is created within the fascia after placing stay sutures. These sutures are used as a purse string to prevent the gas leakage during the case and to help with the closure of the defect at the end of the case. Following this, the peritoneum is identified, grasped between two clamps, and incised sharply. Entry to the abdominal cavity is confirmed visually and by placing a finger into the cavity. The Hasson cannula is then inserted into the abdominal cavity.
The Hasson cannula has three parts: the outer sheath, a blunt obturator, and a cone that is movable along the sheath that may be locked into position. The cannula also has wings at the base of the trocar’s outer sheath where the fascial sutures can be wrapped and locked as shown in Fig. 2.9.
Fig. 2.9
A Hasson cannula is inserted into the abdominal cavity. The cannula has wings at the base of the trocar’s outer sheath where the fascial sutures can be wrapped and locked
2.5 Technique of Creation of Pneumoperioneum
2.5.1 Technique for Creation of the Pneumoperitoneum Using a Veress Needle
Once it has been established that no injury has occurred during the insertion of the Veress needle, one can then progress to insufflating the abdomen. The flow of carbon dioxide gas through the tubing is then confirmed by placing the end of the tube in a water filled container. The tubing is then attached to the Veress needle. The initial intra-abdominal pressure should be <8 mmHg and the flow of gas between 1 and 2 l/min. Satisfactory establishment of the pneumoperitoneum can be checked by watching a gradual rise in the intra-abdominal pressure to 15 mmHg. Percussion over all four quadrants will also confirm establishment of the pneumoperitoneum as shown in Fig. 2.10.
Fig. 2.10
Percussion over all four quadrants also confirms establishment of the pneumoperitoneum
Once the pneumoperitoneum has been established and the patient’s hemodynamic status is confirmed to be stable by the anesthesiologist, the flow of the gas can be increased.
A 10/12 mm trocar is then inserted after withdrawing the Veress needle. The trocar should be held in the palm, with the index finger extended down the shaft to gain maximum control. This is shown in Fig. 2.11.
